Improving TUEs and Installing Health Tests

onWednesday, 14 March 2018

In the wake of last week’s report from the UK parliament plenty readers have emailed in to ask for a reaction. Only it’s hard to have much of a response there’s not much new apart from seeing it printed on parliamentary headed paper and getting front page coverage in the UK media rather than back page or cycling-specific coverage. Whatever the British parliament does, the story is set to rumble on and on and it’s been hard to add to past pieces (here and here). Instead a quick look at TUEs where things have already changed but there’s room for improvement.

Some have said TUEs should be banned. It’s a radical policy and makes the issue a lot easier but it also seems to be a means to get rid of the issue rather to explore it. Abandoning TUEs stops people from taking medicine they need, for example diabetics need a TUE because insulin is on WADA’s banned list. So TUEs have their place. Other voices say TUEs should be made public and certainly knowing who is on triamcinolone, aka Kenacort would be informative but sometimes they can be granted to athletes with reproductive issues or bowel troubles and a degree of privacy here surely should be allowed so publishing them is not necessarily easy.

The problem here is not TUEs per se but the use and abuse of corticosteroids. The UCI says it wants to take action here but it’s a signatory to the WADA Code and corticosteroids are allowed under certain conditions. This is partly down to practicalities between distinguishing between therapeutic use and doping, a lab cannot tell if a sample came from a injection or a local cream. This has been exploited for years, in the late 1990s’ one notorious French rider would rub rock salt into his scrotum until it was red and visit a doctor claiming the soreness was down to chafing shorts and asking for some cortisone cream by prescription. Equipped with permission to use cortisone a cheating cyclist could then abuse it by injection and waive their prescription back at the anti-doping testers. The UCI should have followed its own rules and banned Lance Armstrong in 1999 (how would pro cycling have turned out, a thought experiment for another day?).

Traditionally the UCI has been cautious of going beyond the WADA Code for fear of being sued should a wealthy rider fall foul of a cortisone test because it means the UCI would be alone rather than having WADA as a backstop, both in terms of case law and also legal resources including funding. WADA is looking into this but don’t hold your breath. The UCI’s new President campaigned on a pledge to implement a corticosteroid ban for cycling and we’ll see how he approaches this.

Doctor Zorzoli used to issue TUEs on behalf of the UCI

One area where things have been tightened up since the Wiggins era is the implementation of a TUE Committee, a panel that oversees granting these. In the past it was often the case that one person alone could approve these and when Chris Froome’s TUE at the Tour de Romandie leaked out WADA ordered the UCI to adhere to its standards which includes having a panel of at least three physicians. The UCI implemented this in the wake of the CIRC Report and now three experts have to unanimously agree. This ought to tighten things up a lot, to have three medics agree that only triamcinolone will do is a hors catégorie hurdle to clear compared to a phone call to the previous UCI doctor Mario Zorzoli.

One solution to the gap between ethics and legality is the MPCC. The Movement for Credible Cycling is a self-regulating, voluntary body where teams sign up to rules above and beyond the UCI and WADA Anti-Doping Code. This is no guarantee but it does bring reassurance because the MPCC tests riders for cortisol levels which narrows the gap between ethics and legality when it comes to corticosteroids. This is good twice over. First it can catch riders up to no good. Second it is a useful health check. To explain, cortisol is hormone produced by the adrenal glands which sit on top of your kidneys. When confronted with a shock these glands produce adrenalin but also cortisol in response to the stress. Low cortisol levels can indicate cortisone doping, approved cortisone use via a Therapeutic Use Exemption or possibly a health problem, perhaps a disease or a concern with the adrenal glands so it’s good to stop racing. A rider with low cortisol levels is at risk, if they crash and suffer injuries, perhaps a blow to the head, the body cannot produce its own anti-inflammation response to a cranial injury. So testing riders ahead of, or during, a race can be a useful idea although the science isn’t settled.

The MPCC “health check” sees riders on member teams tested for their cortisol levels. Like an anti-doping test this is random, there’s little warning and the tests could occur at any race. If the rider were to, say, crash then the body would respond by producing cortisol for the inflammation but a rider with low levels could not and therefore the body’s natural ability to recover is endangered. This is particularly worrying in the case of a head injury where the body cannot produce its own anti-inflammation response to a cranial injury.

Nudge theories
Teams can’t be compelled to join the MPCC, that’s the whole point of the voluntary body. However the MPCC has just opened its membership to individual professional cyclists although it’d be awkward to imagine a rider joining because it would only highlight how their team mates and employer won’t although any lone rider joining is to be applauded.

They UCI probably can’t compel them into cortisol level tests either. But the UCI could invite teams or just all riders to take part and a press release issued to say which teams or riders declined to take part and the media could follow up on this. No team would want to start a grand tour with a rider rejecting a health test, the media pressure would be too much.

Similarly if the UCI didn’t want to do this then a race organiser like ASO or RCS could also invite teams to sign up for the cortisol health tests saying they’re free to avoid them but that the test results will be published.

Summary
Things are messy but banning TUEs probably doesn’t fix anything and making them public doesn’t seem right because people may have private medical issues. Some things have changed for the better already such as the UCI having a committee process to review and approve applications. Some of this is closing the old stable door after the horse has bolted but it’s good to fix the door all the same.

There’s room to improve. The UCI wants to go further on corticosteroids but it can’t leave the safe harbour of WADA’s Code and WADA keeps reviewing. Some teams have gone further and the MPCC’s cortisol health tests are a good idea, both to reassure the public and to protect rider health. Not all teams want to join the MPCC but the UCI could copy the MPCC’s cortisol tests, inviting teams and riders to take part and publish the results of those who cooperated… and it would be obvious who refused. If the UCI doesn’t want to, perhaps ASO and RCS could instead?

Something should be done, but what? Where do we draw the proverbial line in the sand? It would seem there is the one hypothetical scenario in regards to cortisone abuse, and the resultant problem I’m sure is statistically improbable. How does this change in regards to cortisone USE, which may reap the same rewards without the hazards mentioned in the article?

Does this apply with Salbutamol? What about Pseudophedrine?

Caffiene, ibuprofen, OTC sleep medication, etc. can also be used in a fashion similar to how modern WT road cyclists attempt to bolster the W/kg formula…popularized by a certain Team Sky. If we think they’re the only ones doing it we are fooling ourselves.

Ross Tucker’s Four Minute Mull (E11) said it best “doping” these days has been replaced by extralegal supplementation. Same result, just a more tedious route to get there.

Destructive eating tendencies like bulimia and anorexia are dangerous to the athlete as well, so should we try and make every cyclist publish their MyFitnessPal data? I kid…but you see the path

Every known stimulant and performance enhancing chemical will never be banned as there will always be legitimate medical need and and sound medical reasons for prescribing a given substance. The rules already recognise this, for example, exactly with things like Salbutamol which can be taken TUE free. In that case a limitation is applied and it is assumed that so much in will equal so much out which is how they decide if people have abused the rules or not. Those who say “ban TUEs” or “ban any medicine that can be abused” are, in my view, simply wishing the problem away at other people’s expense rather than actually wanting to deal with the complex medical needs of a large peloton of hundreds of riders. In essence they are demanding riders who present with no medical history or needs and who never get sick or, if they do, sit idly on the sidelines until they get better – preferably without any medicinal assistance.

To provide some much needed context the below link has a chart showing the number of TUEs granted by the UCI per year. In 2017 they granted 20, YES ONLY 20! This compares to 239 in 2009. Unless these exemptions are now been granted by someone other than the UCI I’d say there isn’t really a TUE problem.

Would be interesting to see the number of TUE applications rejected, and if this has changed in any meaningful way since the shift from one UCI doctor to committee.

It’s a difficult subject as you’d imagine all the team doctors and possibly UCI doctors know each other from races and the wider cycling community. You’d hope that this would not be an issue but the problem with processes is normally the people executing them.

There was a drop in TUEs granted from 25 in 2014 to 13 in 2015, when the new process was introduced. But they’d been dropping by about 10 per year anyway since 2011 (55 granted), so it’s unclear whether the new process made a difference. It’s also unclear whether riders simply got the TUEs from their national anti-doping bodies instead.

i think you’ve suggested before that a neutral doctor, or panel of doctors, employed through the UCI could act as a check to team doctors. if a team or personal doctor suggests a prescription requiring a TUE, the UCI panel would need to review the diagnosis and approve of the TUE.

while that does open a rather large can of worms–of which would be the number of doctors, how they’re paid (is that in the budget?), whether that would be legal under WADA code, who determines the doctors ‘neutrality’–it would at least prevent rampant abuse. riders would not longer have the option of finding a favorable clinic or an obligated team doctor to assign their cough as full fledged asthma.

my other opinion is that we must simply endure the inherent inconsistencies that come with TUE’s and accept the flaws with the process. some riders do get by without proper merit, but i truly believe the vast majority of TUE’s are legitimate. it must feel quite lonely to be a rider with a treatable condition, only to fear absolute reprisal and judgement if the exemption became public: their explanation falling on deaf ears and reputation tarnished or forever altered.

Exactly, Andre Cardoso is just one example. His B-Sample apparently was negative for EPO, yet he’s now banished from cycling and labeled a drug cheat. His ex-colleagues were shocked at the A sample, and suspected him of further harming their livelihoods.

A very lonely place indeed, and he virtually has zero option to either clear his name, race his bike or to really move on with his life because the case is not resolved yet.

@sam: “i think you’ve suggested before that a neutral doctor, or panel of doctors, employed through the UCI could act as a check to team doctors. if a team or personal doctor suggests a prescription requiring a TUE, the UCI panel would need to review the diagnosis and approve of the TUE”

That describes the current process. As set out in the article, before 2014 a TUE only had to be signed off by Dr Zorzoli, now it must be signed off by a panel of 3. One of the few Cookson changes I can actually remember.

The real problem here are TUE’s, not some hapless, poorly informed British Parliamentarians, who have misused their protected status as a stick to beat Murdoch, and in the process have done great damage to an athlete, team sponsor and the sport in GB. The continental media don’t appear to be equally exercised.

The basic and simplest stand on this issue would be that if an athlete requires medication to complete, then he/she should not compete. No exceptions. Unfair on athletes with treatable conditions of course, but to do nothing leaves athletes reputations tarnished and the sport bought continually into disrepute. The world of cycling would surely be a better place if a no TUE policy were introduced. To keep a system that clearly introduces problems and questions for athletes, who have simply followed the rules, and in addition causes major sponsors to consider their future in the sport, can be of little benefit to anyone.

It’s a difficult conundrum for sure, as the non TUE case of Froome illustrates. The UCI needs to take a lead for once, and make its position clear, and not hide behind WADA.

that assessment is really a non-starter. declaring that a treatable illness or condition prohibits an athlete from competing is most certainly a form of discrimination and a rather large step backwards medically speaking considering the routine nature of some of the exemptions.

what you’re saying is a bit audacious: that only perfect human specimens are allowed to compete at the highest level. you don’t have to run many hypotheticals to find where that hits some moral and legal issues: a junior can’t race and should abandon their dream due to an unforeseen turn of health or genetic anomaly?

while it’s understandable to be intolerant given recent events and historical context, it is not admirable to hold the son accountable for the sins of the father.

Agree that doing away with TUEs would be a step backwards, but I believe that making them public would go a long way to solving the problem. Yes, I understand the privacy implications, but this is elite sport and sacrifices are the price of admission. Whereabouts tracking and random drug testing are accepted and rather than nudging the sport to a cleaner place, a hard decision should be made and, in time, it too will be accepted.

Maybe a compromise would be to make (the general details of) TUEs public, but do so anonymously. Still not perfect, of course, as there’s still the potential for the media and others to start digging around trying to link them to a particular rider, but perhaps if they were out in the open it would no longer be interesting enough for anyone to bother.

sam. I am not indicating that the complete banning of TUEs as something that is likely to happen. Many people would have liked to excel in pursuits that don’t suit their personal characteristics – we are not all born equal, that is not a moral or legal issue, it’s a generic fact.

What I am pointing out is that athletes and sponsors are being attacked, their sacrifices trashed and effectively being called out for cheating, by following the very rules that exist today. Those calling them out show little understanding, or if they do choose to ignore the reality, be they politicians, journalists or posters on sites like cyclingnews.

To continue with the present situation is not sustainable if the sport is to move on from its past. That should be clear to everybody. Defending a known problem is never the path to resolution.

If you allow TUE you are always going to have to draw an artificial line somewhere.
If you don’t then you have a hard (unfair?) line already.

I don’t have asthma – why do I get penalised for that? I have to compete with many people who get a +5% performance boost.

Elite sport is discriminatory already. Why shouldn’t it be only the perfect human specimens that gets to compete? Isn’t that the idea? A competition to find out who is that specimen?
Phelps has disproportionate torso to leg length, giant hands and wide shoulders – he has a massive advantage – its always going to be unfair on some skinny kid with a dream to be Olympic No1 swimmer.

why would Damien Collins, a Tory MP, have a beef with Murdoch? What the committee did achieve was to get an acknowledgement from Sky (Sutton) that they gamed the TUE system to take advantage of PEDs, despite Brailsford’s obfuscation and Freeman’s/Wiggins non appearances. Wiggin’s reputation has taken a deserved hit as a result. A great shame, but that’s the way it is.

Just stop giving TUEs for substances that should be reserved for people who are intensive care, that would be a good start.

I guess that part of the problem is the ‘science’… pharmacology isn’t maths, so we can’t truly quantify how much of an advantage each substance provides in every condition to every shape and size of cyclist. But if we could, the drugs that turn us into Usain Bolt should never be authorised.

It took me a while to understand this comment. At first I thought you were referring to Wiggins himself. After a bit of pondering I decided that maybe “externally routed cables” meant protruding veins. Only after a while did I realise you were referring to his bike 🙂

Most of the TUE problems discussed and highlighted seem to turn around the failure of the issuing doctor to respect the relevent UCI clause 4b:

b. The therapeutic use of the prohibited substance or prohibited method is highly unlikely to produce any additional enhancement of performance beyond what might be anticipated by a return to the rider’s normal state of health following the treatment of the acute or chronic medical condition.

The key element being “highly unlikely to produce any additional enhancement of performance…”. A number of TUEs granted in the past have clearly failed to satisfy this requirement indicating some form of understanding or collusion between the applicant team and issuing authority. If future TUEs do satisfy the requirement, it would seem hard to object to both the continuation of TUEs and thier confidentiality.

On the MPCC question, IR must surely be correct that individual adhesion is hard to imagine, though the announcement provides some MPCC publicity and highlights again teams declining to adhere – mainly it seems for reasons of convenience.

Given that apparently only 20 TUEs were issued in 2017, and seemingly none for those who might actually win a big race, how much of an issue is the TUE really? As per comments above their numbers have been steadily but consistently declining over the last decade. If the TUE was ever a means to legally subvert the rules it seems the smart money is moving out of that into something else.

Part of the problem is that “clearly failed to satisfy this requirement” is inherently a matter of opinion, and mostly opinion based on limited, and limited quality, evidence, or, worse, anecdote. It’s impossible to objectively calculate, for any given athlete, how big the performance deficit due to illness is, how much will be regained due to the medical treatment, and how big any (non-medical) performance enhancement will be.

Note that the requirement doesn’t say that the treatment cannot give any performance enhancement; only that any performance enhancement cannot take the athlete above the level that they would have been at without any illness or treatment. If an athlete’s performance is down by 5% as a result of illness, and they get 3% back as a result of treating the condition and 2% from other performance enhancement, that is permitted.

That leaves it open, particularly when the science is very limited, for any individual to hold, or at least claim to hold, the opinion that it’s not going to “produce any additional enhancement of performance beyond what might be anticipated by a return to the rider’s normal state of health”, even if many others disagree.

Would love to know who the notorious French scrotum masochist was! But I suppose you might get in trouble for naming?

Maybe there just needs to be a more sensible list of what you can use to treat what? I am not aware of any ‘civvie’ being prescribed an injection of kenacort for asthma or hay fever sniffles! That’s the only issue for me, i don’t think its as big a deal as folk are making out.

The ruse of saddle sores was to ask for a product called Cemalyt, a topical cream that contains triamcinalone (aka Kenacort) and therefore a rider could inject triamcinalone and if caught say it was the Cemalyt prescription. Lance Armstrong said he used Cemalyt in 1999 and many others were using it, this was systemic rather than just one rider but the practice was cited by the late Philippe Gaumont who also said he and others were advised to complain of allergies in order to ask for a nasal spray called Nasacort which again contained triamcinalone. Riders were finding all sorts of ruses to get this substance.

The ruse of being able to get a cream or nasal spray prescription to cover up an injection died off completely during the early to mid-2000s. Labs began checking the concentration was correct for the prescribed dosage and administration route and date and call out anomalies. Even now many hay fever cortisone nasal sprays are legal without prescription under Wada if taken by nasal spray in line with standard dosage.

Like you Richard, I am also not aware of members of the public getting injections of performance-enhancing drugs to deal with their asthma (or is it hay fever, Wiggins never seems quite sure) before what just happen to be key performance targets in two different countries, in different weather conditions and at different times of year for a condition I claim to have had since 2003 but, somehow, fail to have taken for a similar situation in 2009 where I finished 4th.

“The UCI can’t go beyond the WADA Code for fear of being sued…” Really? I think UCI prevents the use of motorized bicycles in their events, no? But I don’t think you’ll find any mention of this in the WADA code.
UCI can do whatever they wish – write the rules, then inform the interested parties who can conform to the rules as written or…..(wait for it)….go paint houses.

WADA = World Anti-Doping Association pretty much says it all, doping is kind of their thing.

Larry T – you’ve been a fan long enough to realise UCI has very little stick to write a rule that everyone has to follow without any pushback! Inrng’s bang-on, if the rule does not have support from the other stakeholders (WADA, riders, organisers, teams, etc.) then it won’t fly and will be open to costly legal action that UCI cannot afford.

Note that I wrote the UCI CAN (and SHOULD) …not that they will. They have a fear of lawsuits along with fears of plenty of other things like guys named Armstrong or at present Froome.
But currently neither the UCI or the riders themselves seem to have the collective will to do much more than whine – and wonder why their sport is in such decline in the mind of the general public. It seems that it’s ALWAYS up to someone else to be the one to step up and take action.

This is because the UCI lives in the real world where standing with others such as WADA actually bolsters their legal position. We do not live in a world where noble athletes compete in sports ruled by well-meaning legal bodies and everyone plays fair. We live in a world where if you step beyond the established legal norms you might get taken to the cleaners. The UCI is not a rich organisation as INRNG shows us annually when he discusses their financial reports. You talk about whining but my bet is you wouldn’t so much if the continued financial health of your organisation relied on dotting every “I” and crossing every “T”. In that respect, following the established practice of the sporting drugs body is vital.

The names are there to be seen, but not sure about shaming them. We should though be asking questions about why they don’t want to join and if they don’t want to join, whether they’d just settle for being part of cortisol health testing program?

If there’s out of competition cortisol testing, would riders then need a TUE just to train if they had a health problem?
Or would they just be expected to stop and recover?
It doesn’t male sense, what if you base your entire season around one target race and then you have to sit it out because of an issue that could be otherwise treatable?

My comment was slightly rhetorical and I know that the membership information is freely available. Only 7 out of 18 World Tour teams and 22 out of 27 pro continental teams are members. That’s an indictment on the top league. It’s pretty obvious that Team Sky (amongst others?) have been gaming the existing system and the strictures of the MPCC code would have cramped their approach.

If Sky have been following the rules, as even the DCMS committee said, then their “gaming” of the rules is a matter of the ruling body tightening the rules not of the joining of voluntary bodies when the vast majority of your direct peers in the World Tour aren’t members either.

Obv it’s best that all teams would be part of MPCC, but any non-MPCC teams will tell you they’re not part of it because the WADA code is already stronger than any other pro league.

Clearly you’ll never get them to admit the real reason why they don’t want MPCC. I think it’s fairly obvious, why would Sky adopt it if Movistar wouldn’t? Then Movistar will clean up the GT’s is the logic because those extra, err…. “treatments” make that much of a difference.

For the remaining teams, signing up for MPCC is an all or none thing.

We need practical solutions, there’s no point getting upset that competitive organisations don’t want to do something that levels the playing field.

Couldn’t WADA in theory implement a procedure for individual sport’s unions to ask to go “beyond the WADA Code”? Given that the UCI has good arguments to do this, it might help to legally tighten the extra rules they employ. When the arguments to do this are sound (according to WADA or something like that), they could see it as a specific addition to the WADA code (just for that sport). Or does a procedure like this exist already?

I very much like the idea of an individual joining the MPCC at there own volition. Because of the arbitrary nature of the sport. I’m fairly certain I’d feel strongly enough to join. Even if the employer frowned upon the idea. And it cost me my job. You’ll either end up somewhere like Tim Wellens is. Or digging potatoes 🥔 although there is another option. Hunting thé floury blighters on a ProConti/Continental Team

Making TUE’s public will help stop the abuse. It’s unfortunate that this encroaches on riders’ right to privacy (and so would require their consent), but the privacy is very likely to be breached in the important cases anyway, and probably for the good of the sport. Wiggins’ situation was an illustration of this. It also showed that Sky’s reassurances in 2012 and 2013 that they were doing everything by the rules obscured their belief that some rules are to be exploited/gamed for advantage, if not broken. The 2009 interview between Lionel Birnie and Brailsford shows Sir Dave that has never had an adequate appreciation of the ethical issues involved. After reading that it is not surprising that Sky’s approach in those days exposed a certain amount of bad-faith on their part. The good news is that they established that gaming TUE’s is not the same as playing by the rules, so I wonder whether that in itself might cause less TUE abuse at least among top riders, knowing that the TUE will likely become public and will not be seen as “perfectly legal.” Chris Froome has been aware for years that it’s important for him to be able to say he has no current/recent TUE’s…but was apparently not quite ready to give up on pharmacology altogether.

Exactly, that’s the ultimate point. Right from the beginning, Sky has been ahead of the testers, and you can bet your life they’re still using products/methods that may not be illegal, but likely are not what an amateur would do and in fact may be deemed illegal in a few years time.

Froome “was apparently not quite ready to give up on pharmacology altogether” because he has a legitimate breathing problem which any number of journalists and others will attest to as they have all witnessed him endlessly coughing after stages, the result of phelgm building up on his chest. The suggestion he isn’t “giving it up” seems to imply you think he seeks to gain advantage from it rather than simply be able to breath and so compete. He’d likely not be racing to win without it. Since what he takes is a legal drug that thousands of regular civilians take (we all know people with THE SAME inhaler) this is hardly the same as even the Wiggins case, for example.

The vexed issue of TUE’s will continue to dog cycling unless a firmer line is taken with the health assessments made by the doctors on the teams. By this I mean if it is adjudged that any rider is unfit to ride without the use of a normal banned medicine then he/she should not be allowed to race. This will be difficult with chronic conditions such as diabetes and asthma. However there is a crucial difference between these two conditions in that diabetes is a constant for which the only treatment is insulin. (It must be debatable the extent to which insulin is performance enhancing) Asthma however is a variable condition with varying degrees of severity often affected by a wide range of environmental factors. If an attack is so serious as to require a corticosteroid then it is reasonable to judge that the rider should not be allowed to race. Clearly there are the risks of legal restraint of trade challenges if riders feel that their right to make a living is threatened by a new harder line regime. I can see the messy grey areas resulting from the current TUE regime continuing unless a much stricter regime is put in place. The suggestions made above for panels of doctors at both the team and UCI ends may encourage a more rigorous approach.

This is an avoidance of the issue. Froome, for example, is not taking a banned medication. It is one with wide usage in general society and it doesn’t even need a TUE. So on your analysis he SHOULD be allowed to race.

It is banned at the levels he had in him.
We all do know people who use inhalers – and we who use them know that more than two puffs has no effect.
So, why would Froome have taken so many puffs? He would not.
So, then it comes down to Froome having very strange kidneys or the drug being in his system from other methods.
The kidneys idea is about as plausible as Wiggins’s date-selective asthma.

If the inconsistency in the comments above represents the general view, then TUEs are the problem.

Interesting range of views. Comments range from the well informed to the wildly accusatory of the amateur ‘dope sleuths’, SS mind readers and everything in between. There clearly is only one obvious solution, and that is to ban TUEs completely -no if or buts, no half measures. If you need medication to be competitive, then you should ride the bike to enjoy yourself and find other gainful employment. Forget the PC stuff, the potential legal implications, the unfairness and simply apply common sense over this issue. The MPCC have not found themselves up before the beak over their policy !

To continue to ignore the obvious will undoubtedly lead to more confusion and division, and leave the sport open to continuing bad publicity, over what is perceived by many as doping.

BC is not wrong. The simplest and cleanest resolution of this mess is to simply ban TUE’s altogether, however to do this will undoubtedly penalise many diabetic riders who would no longer be able to ride. Unless of course the WADA and the UCI see sense and removes insulin from the banned list.

A last thought. What links taking EPO and sleeping in an oxygen tent? Yes both increase red blood cells…..one is deemed cheating while the other is not….presumably seen simply as marginal gains. Thoughts on a post card please!